Major depressive episode
DSM Classification
(The psychiatry bible)
Major Depressive Disorder, Single Episode
Diagnostic criteria
- Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
- depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
- markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
- significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
- The symptoms do not meet criteria for a Mixed Episode.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
- The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia , Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.
Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.
Sensible Psychology Definition
Feeling so miserable that you can’t cope with everyday life or enjoy yourself.
The DSM distinguishes a true ‘major depressive episode’ from other psychiatric diagnoses such as bi-polar disorder (‘manic depression’) and schizophrenic and other psychotic illnesses. So a major depressive episode is a period of intense sadness (and often other strong emotions such as fear and anger) and loss of motivation in an otherwise healthy individual.
How long does a depressive episode need to last to be an ‘episode’? The basis of the DSM’s 2-week minimum is not explained. We know that people can dip in and out of depression for months or even years.
Depression is essentially a state of high stress (1) caused by worry, guilt, negative ‘circular’ thinking and poor sleep, leading to emotional and therefore physical exhaustion. (2)
Depression used to be known as ‘nervous exhaustion’ – in our opinion a much more useful name, as it actually describes what depression is. Stress exhausts the system, leading to the collapse of motivation and energy.
Depressed people:
- have disrupted sleep patterns which always include dreaming too much and so having insufficient restful and reviving slow-wave sleep (this is why depressed people can feel so tired even after a long sleep (3) – a fact the DSM totally neglects to mention)
- feel unmotivated to work, see people or even seek help because of loss of hope (another symptom)
- think in all or nothing terms (also a risk factor for developing depression) and often have a tendency to perfectionism (4)
- have difficulty planning and thinking clearly because stress impedes the proper functioning of the brain (5)
- lose confidence to do even quite simple tasks that would normally feel easy
- are extremely pessimistic, and full of foreboding and dread
- feel guilty and sad about the past
- lack enjoyment and satisfaction
Anyone can get depressed
It’s a myth that depression is genetic or works like a chemical disease and that drugs are the only real way to lift it.(6) Most depression will lift spontaneously after around five months.(7) Anyone can be depressed for a while but some people are more prone to depression. No gene for depression has yet been found.(8) However, we can learn depressive attitudes and thinking styles from parents or other care givers and even from people we socialize with.(9)
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Genes just don’t change that quickly. And there is little to no evidence that a chemical imbalance causes depression (although depression certainly does bring about chemical changes in the brain, like any other emotional state). Of course, drug companies, and those who indirectly work for them (some psychiatrists?), have a vested interest in promoting the ‘chemical imbalance’ theory. However, it seems more likely that the interplay of the expectations and stresses of modern life may be what is making us more depressed.(11)
Treatment for depression
The commonest treatment for depression by far is anti-depressant medication (see Drugs and medications). Psychotherapy or counselling may also be prescribed.
The sensible psychology approach
The experience of depression is horrible both for the sufferer and for the people in their lives who have to stand by and see such unhappiness in a loved one. Mixing with people who are depressed makes us more likely to become depressed ourselves.(12) Conversely, when we lift ourselves out of depression we help everyone around us too.
Research shows that the right type of psychotherapy(10) is both more effective at lifting depression and also preventing future relapse back into depression.
Effective therapy for depression will help you:
- learn how to relax deeply and regularly to lower stress levels
- regain a balanced perspective
- take practical steps to solve worrying problems, whether by making life changes or by learning to feel and think about what was troubling you in a different way
- decrease negative introspection and worry
- focus outward
- restore healthy sleep patterns to increase energy and motivation
- see the pattern of depression ‘from the outside’ so that you know what’s happening and can take steps to stop it happening for yourself in future.
We use relaxation and hypnosis to both calm down the agitation of depression and help rehearse new ways of behaving and thinking which are non-depressive.
The DSM classification takes no account of the contribution of excessive dreaming to prolonged depression, nor of the ‘social effect’ of depression that leads to the people around becoming more susceptible to depression.
There is hope – but when you are depressed it’s hard to know that!
An important indication that depression is lifting is the forming of a new, more realistic perspective that allows the individual to see that what had seemed a permanent state of depression was, in reality, a temporary episode.
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About Mark Tyrrell
Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.
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Notes:
- Even though depressed people seem flat and passive on the surface, underneath strong emotions such as fear and anger and strong anxiety do their work. For example, it’s been found that depressed people always have higher than normal levels of the stress hormone cortisol in their blood stream. See Nemeroff, C.B (1998) ‘The neurobiology of depression’, Scientific American, 278,6, 28-35.
- See ‘The Dreamcatcher’. New Scientist, April 2003
- ibid.
- See: Rice, Kenneth G.; Aldea, Mirela A., ‘State dependence and trait stability of perfectionism: A short-term longitudinal study.’ Journal of Counseling Psychology, Vol 53(2), Apr 2006, 205-213. This strongly suggests that perfectionist tendencies drive a vulnerability to depression.
- See: Austin MP, Ross M, Murray C, O’Carroll RE, Ebmeier KP, Goodwin GM. ‘Cognitive function in major depression.’ Journal of Affective Disorders, 1992 May;25(1):21-9.
- See: Danton, W. Antonuccio, D. and DeNelsky, G (1995), ‘Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data.’ Professional Psychology Research and Practice 26, 574.
- ibid.
- See: The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch PhD (Bodley Head, 2009)
- See: Rosenquist JN, Fowler JH, Christakis NA. Social network determinants of depression. Mol Psychiatry. 2010 Mar 16.
- See: Danton, W. Antonuccio, D. and DeNelsky, G (1995), ‘Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data.’ Professional Psychology Research and Practice 26, 574.
- In societies where feelings of community are strong, families are connected (i.e. the extended family is still cohesive), and where there are coherent shared belief systems and a sense of attachment to a culture or system greater than oneself, depression is virtually unknown (e.g. tribal societies such as the Kaluli in New Guinea, Amish society, etc.) When traditional societies become industrialized, vulnerability to depression very quickly establishes itself (belying the idea that depression is mainly caused by ‘faulty genes’). See: Danton, W. Antonuccio, D. and DeNelsky, G (1995), ‘Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data.’ Professional Psychology Research and Practice 26, 574
- See: Rosenquist JN, Fowler JH, Christakis NA. ‘Social network determinants of depression.’ Molecular Psychiatry (2011) 16, 273-281.
